Mini-cex: an assessment tool for observed evaluation of medical postgraduate residents during their training program: an overview and recommendations for its implementation in cpsp residency program

The mini-CEX is a workplace-based assessment to assess professional performance of medical trainees. Proper reporting of the gap between desired and observed performance forms the basis and the incentive for the trainees to improve their skills. It plays a key role by combining learning with assessment There is an urgent need for including this form of assessment in our clinical training programs especially postgraduate residents training

Age and gender specific stroke risk factors in a teaching hospital in Khyber Pakhtunkhwa

To determine age and gender specific stroke risk factors in a teaching hospital in Khyber Pakhtunkhwa. A hospital based descriptive study was performed in medical units of Lady Reading Hospital, Peshawar, from July 2011 to March 2012. A total of 100 patients of 18 years and above and of both genders were included. Study patients with first-ever acute stroke were divided into three groups; Group A young adult [<40 years], Group B, middle-aged [40-60 years], and Group C elderly [>60 years]. In these 03 groups, stroke risk factors were compared. Patients were assessed for hypertension, ischemic heart disease, hyperlipidemia, atrial fibrillation, diabetes mellitus and smoking. SPSS version 18.0 was used for statistical analysis. A sample of 100 patients was taken comprising 68% males and 32% females. Study patients had a mean age of 63.44 +/- 13.849. There were 08 patients in Group A, 29 in Group B, and 63 patients in Group C. Overall, hy-pertension was found in [62%], followed by smoking [47%], coronary artery disease [33%], diabetes mellitus [28%], hyperlipidemia [24%] and atrial fibrillation [21%]. Pattern of distribution of stroke risk factors is age and gender specific. Majority were found to have hypertension. Hypertension, diabetes mellitus, atrial fibrillation and hyperlipidemia differ significantly among the 03 age groups. Smoking was significantly different in males and females

Effect of pioglitazone on lipid profile in type 2 diabetic patients

To determine the effect of pioglitazone on lipid profile in type 2 diabetic patients treated and followed up for three months after initiation of therapy. This hospital based quasi-experimental study was conducted in the medical B unit, Lady Reading Hospital Peshawar from July 2008 to June 2009. A total of 161 patients with type 2 diabetes mellitus were included in this study using convenient [non-probability] sampling. Clinical and laboratory evaluation of all the patients were done to note the change in lipid profile after the use of 30 mg pioglitazone. Continuous variables such as age and lipid profile [triglycerides; Low Density Lipoprotien [LDL]; High Density Lipoprotien [HDL]; cholesterol] at baseline and after 3 months time were expressed as mean +/- S.D. Paired sample t-test was used to analyze the mean difference in pre-post lab investigation by SPSS version15. Out of the 161 patients, 79 [49.1%] were males and 82 [50.9%] were females. The mean age of the sample was 51.2 +/- 11.33 years. Triglycerides decreased from 219.2 +/- 34.4 to 189.2 +/- 33.7 mg/dl with a mean difference of 29.9 mg/dl [p<0.001]. Total cholesterol changed from 201.4 +/- 29.8 to 203.2 +/- 28.9 mg/dl with a mean difference of 1.8mg/dl [p<0.001]. LDL changed from 153.7 +/- 21.1 to 154.7 +/- 20.7 mg/dl with a mean difference of 0.9 mg/dl [p<0.001]. HDL increased from 37.2 +/- 2.9 to 41.5 +/- 3.1 mg/dl with a mean difference of 4.3 mg/dl [p<0.001]. Pioglitazone was found to have beneficial effects on lipid profile. It significantly reduced the levels of triglycerides and increased levels of HDL cholesterol in patients with Type 2 diabetes

Anti-cyclic citrullinated peptide antibodies as a tool in diffrentiating patients with rheumatoid arthritis from patients with chronic hepatitis C infection-associated polyarticular involvement

To assess the utility of anti-cyclic citrullinated peptide [anti-CCP] antibodies in distinguishing between patients with rheumatoid arthritis [RA] and patients with polyarticular involvement associated with chronic hepatitis C virus [HCV] infection. All the patients enrolled in this study were examined in the outpatient department of medicine unit at Lady Reading Hospital Peshawar from February to December 2010. Serum anti-CCP antibodies and rheumatoid factor [RF] were evaluated in 29 patients with RA, 13 patients with chronic HCV infection a associated with articular involvement and 35 patients with chronic HCV infection without any joint involvement. Anti-CCP antibodies were detected in18 of 29 [62.1%] patients with RA, 7 of 13[53.8%] patients having HCV with RA like arthropathy but not in a single patient with chronic HCV infection with no articular involvement. Conversely, RF was detected in 25 of 29 [86.2%] patients with RA, 9 of 13 [69.2%] patients with HCV-related RA like arthropathy and 8 of 31 [22.9%] patients with HCV infection without joint involvement. This concludes that anti-CCP antibodies can be useful in discriminating patients with RA from patients with HCV-associated arthropathy

relationship between the clinical manifestations and the presence of anti cyclic citrullinated peptide antibodies in very early rheumatoid arthritis

To establish whether the clinical presentation of anti-cyclic citrullinated peptide [Anti-CCP] antibodies and negative disease are distinct at the earliest clinically apparent phase of disease. Patients were seen in outpatient department of Lady Reading Hospital Peshawar from February 2009 to February 2011. Participants were included in the current study if they presented within 3 months of symptom onset and fulfilled 1987 ACR criteria for [RA] in the beginning or at some point during an 18 month follow-up. Data were collected on demographic variables and joint symptoms [tender and swollen joint counts]. C- reactive protein [CRP], erythrocyte sedimentation rate [ESR], rheumatoid factor and Anti-CCP antibodies status were measured. 110 patients were included [57 were Anti-CCP antibodies positive]. The Anti-CCP antibodies positive and negative groups were comparable in terms of demographic variables, inflammatory markers,tender and swollen joint counts and 1987 ACR classification criteria. Rheumatoid arthritis factor was detected more in Anti-CCP antibodies positive patients as compared with Anti-CCP antibodies negative patients. [83.3% vs. 35.8%]. There was no significant difference in the pattern of joint involvement, except for an increased prevalence of knee joint swelling in Anti-CCP antibodies positive patients [56.1% vs.17.5%]. Patients with and without Anti-CCP antibodies present in a similar way, even within three months of clinically apparent disease that eventually develops into Rheumatoid arthritis

Effect of pregnancy on the disease activity in ulcerative colitis

To study the effects of pregnancy on the disease activity in ulcerative colitis. This experimental study was conducted at department of Medicine at Sultan Qaboos University Hospital Oman from July 2002 to December 2004. A total 60 diagnosed cases of ulcerative colitis proven on colonoscopy and biopsy and fairly well controlled disease at the time of enrollment were included in the study. Those who conceived and delivered during the study period were inducted as experimental group [total 30 patients], and those who did not conceive during the study period were inducted as control group [total 30 patients]. Out of total 60 patients, 30 patients who were included in the study group, 24 remained well with mild exacerbation requiring only increased dose of mesalamine, four patients had moderate disease exacerbation requiring oral steroids along with mesalamine. Two patients had severe exacerbation that was controlled on parental steroids. Among control group, 25 had mild exacerbation, 4 had moderate exacerbation and 1 had severe exacerbation during the study period. The eventual out come was good in all patients. It is thus concluded that a planned pregnancy when the disease is well controlled minimizes the risk of complications in patients of ulcerative colitis and also has got favorable outcome of pregnancy

Short-term effectiveness of methotrexate in the treatment of active rheumatoid arthritis

To determine the effectiveness of 6-month treatment with methotrexate in a dose range of 5-15mg once weekly in 103 patients with active rheumatoid arthritis. This descriptive study was conducted in outpatient department of Medical B unit Lady Reading Hospital from October 2008 to August 2009 and included 103 active rheumatoid arthritis patients who received methotrexate in a dose range of 5-15mg once weekly for 6 months. The primary efficacy endpoint was a >/= 20% response according to the American College of Rheumatology response criteria 20 and disease activity score 28 after 6 months. Female patients made up 51.5% of the study population while males were 48.5%. The mean age was 46.1 years and the mean disease duration was 10.90 +/- 3.42 years. According to the disease activity score 28, 30.1% of patients had good while 38.8% had a moderate response. 31.1% were non-responders. Mean improvement in tender joint count were -8.3 +/- 4.59 [from baseline of 15.54 +/- 5.85] and in swollen joint count were -7.37 +/- 3.98 [from baseline of 10.59 +/- 4.96]. ESR improved to 15.24 +/- 10.42 from baseline of 58.7 +/- 11.16 and physical global assessment improves to 34.42 +/- 20.43 from baseline of 66.21 +/- 10.58. At 6 months, the rate of American college of rheumatology response criteria 20 was 68.2%. Treatment related adverse events were reported in 27.2% of patients. The study showed a favorable effectiveness for methotrexate in a dose range of 7.5-15mg once weekly

Yield of plain film radiograph in the diagnosis of osteomyelitis in patients with diabetic foot in a tertiary care hospital

To determine the yield of plain film radiograph [PFR] in the diagnosis of osteomyelitis in patients with diabetic foot in a tertiary care hospital. This hospital based non-interventional, descriptive study was conducted on 60 patients. Patients of both sexes, above the age of 12 years who were known diabetics and were clinically thought of osteomyelitis were included in the study. These patients were admitted in medical wards of Post Graduate Medical Institute, Lady Reading Hospital Peshawar, from January to December 2002. Patients were selected by non-probability convenient sampling method after obtaining an informed consent. Out of 60 patients, 14 [23.33%] were having type I Diabetes Mellitus [DM] and 46 [76.66%] patients were having type 2 DM. Age of the patients ranged from 24 to 75 years, with a mean age of 52.4 years. Twelve patients [20%] had history of trauma and 21 [35%] patients had ill-fitting shoes, as risk. factors for diabetic foot. Plain film radiograph detected changes of osteomyelitis in 37 [62.57%] of patients, with a sensitivity of [77.08%] and specificity of about 75%. Plain film radiograph yields valuable anatomical Information at a lower cost. II has a reasonably good detection power and its easy availability even at primary and secondary care centers makes it the imaging of first choice in the study of diabetic foot. It could be followed by a three-phase, bone scan and additional imaging as and when needed

Clinicicopathologic profile of patients presenting with abdominal tuberculosis in a tertiary care hospital

To evaluate pattern of presentation of patients with abdominal tuberculosis [TB] in a tertiary care hospital. This was a hospital based non-interventional descriptive case series study. It included patients of both sexes, more than 12 years of age, with clinically suspected abdominal tuberculosis. The study was carried out in medical wards of Lady Reading Hospital, Peshawar from January to December 2003. Patients were selected by non-probability convenient sampling method after obtaining an informed consent. Out of 100 patients with abdominal TB, there were 62 [62%] patients with intestinal TB, 30 [30%] with peritoneal TB and 08 [08%] patients with nodal TB. The mean age of patients was 36.4+9.64 years. Fever was observed in 74 [74%] patients, weight loss in 42 [42%], abdominal pain in 72 [72%] diarrhoea in 53 [53%], vomiting in 49 [49%], abdominal mass in 34 [34%], and ascites in 36 [36%] patients. Montoux test was positive in 67 [67%], immuno-chromatographic testing [ICT] for Tuberculosis., was positive in 62 [62%] patients. Chest radiograph was abnormal in 24 [24%] patients, Abdominal Ultrasonography showed abnormalities in 72 [72%] patients.. Barium contrast studies showed abnormalities in 77 [77%] patients. Computerized tomography [CT] of the abdomen was abnormal in 84 [84%]. Intestinal tuberculosis was the most common entity in patients with TB abdomen. The most frequent presenting features of abdominal TB were fever and abdominal pain. CT abdomen had the highest diagnostic yield

Spectrum of precipitating factors of hepatic encephalopathy in liver cirrhosis

To ascertain the spectrum of precipitating factors of hepatic encephalopathy in patients with liver cirrhosis. descriptive study. The study was conducted in the department of medicine, medical B unit of Postgraduate Medical Institute, Lady Reading Hospital, Peshawar over six months. All patients with cirrhosis of liver[CL] of more than 12 years of age, manifesting signs of hepatic encephalopathy [HE] were included and those who had acute fulminant hepatitis or had noncirrhotic portal hypertension were excluded from the study. Detailed history, clinical examination and thorough investigations were done to look for any precipitating factor and the findings were recorded on a proforma. Fifty patients [32 males and 18 females] were enrolled. 47 patients had hepatitis B, C or both positive. 64% were in the age group of 45-60 years and 76% were having either grade III or IV coma. Thirty three [66%] patients had asterixis which was found to be a sensitive index for the diagnosis of HE in patients who were not in coma. Jaundice and Ascites were other common presenting features. Electrolytes imbalance in 28[56%] patients, diarrhea in 20[40%], constipation in 16[32%], infections in 12[24%] and gastrointestinal bleed in 11[22%] patients were amongst the commonest precipitating factors. None gave the history of alcoholism or recent surgery Occurrence of precipitating factors for HE in patients with CL is a common phenomenon and all such patients must be hospitalized to ascertain and manage such factors

Risk factors stratification in 100 patients of acute stroke

To find out the relative frequencies of various risk factors associated with first ever stroke. This prospective observational study was conducted in medical B unit of the Department of Medicine, Post Graduate Medical Institute, Government Lady Reading Hospital, Peshawar, Pakistan from March 2001 to January 2002. A total number of 100 patients, 64 males and 36 females, with first ever stroke were included in the study. A questionnaire was designed comprising detailed history, general physical and neurological examinations. The association of different risk factors with stroke was studied. The ages of patients ranged from 17 to 100 years with mean age of 59 years +11.63 years standard deviation [SD]. Cerebral infarction constituted 68%, intracerebral hemorrhage 31% and subarachnoid hemorrhage 01%. Hypertension [HTN] was the most common risk factor [60%] followed by diabetes mellitus [DM] [28%], hyperlipidemia [28%], smoking [22%], ischemic heart disease [IHD] [18%], atrial fibrillation [12%] and history of oral contraceptive use [10%]. Main risk factors for stroke are Hypertension, Diabetes mellitus, Hyperlipidemia and Smoking. Stroke can be prevented by modification of these risk factors. There is a genuine need for health education programmes on stroke and their mortality

Renal tubular acidosis: a case report

This case report describes a 19 years old boy presenting with bilateral lumbar pain, abdominal cramps and generalized bodyaches. Systemic examination was unremarkable. Patient was diagnosed as Type I Renal Tubular Acidosis on the basis of alkaline urine, nephrocalcinosis, hypokalemic hyperchloremic metabolic acidosis with normal serum anion gap and positive amrnonium chloride challenge test